Basic Clinical Massage Therapy

Plate 7-1 Skeletal features of the abdominal region and lower back P.269

Plate 7-2 Muscles of the anterior abdomen P.270

Plate 7-3 Abdominal and lower back muscles, lateral view P.271

Plate 7-4 Muscles of the lower back P.272

Plate 7-5 Surface anatomy of the abdomen and lower back P.273 Overview of the Region The waist, which includes the low back (lumbar region) and middle abdomen, is a very vulnerable area because of its lack of bony armor and support. Above, the torso and spine are stabilized and the internal organs protected by the rib cage. Below, the pelvis provides stability and protection. In between, however, our need for flexibility and mobility require a space with very little support or protection. The muscles of this region, therefore, have a lot of work to do and are easily stressed or injured. Their primary actions are movement of the upper body in relation to the lower and vice versa: anterior flexion, lateral flexion, and rotation of the torso. Trigger points in these muscles refer to an extensive territory: upward into the back and chest; inward into the viscera; and downward into the buttocks, lower abdomen, groin, genitals, and legs. The lower back region is characterized by several layers of thick, strong tendinous and fascial tissue, including the thoracolumbar fascia and tendinous portions of the erector spinae and latissimus dorsi. These connective tissues may themselves become tight, congested, and tender, and they should be treated along with the muscles. P.274

Muscles of the Abdomen Comment These muscles form the wall of the abdomen, and include rectus abdominis, transversus abdominis, and the external and internal oblique muscles. Aside from their various primary functions, all of these muscles assist in forced exhalation through compression of the abdominal cavity. They are extremely important clinically, as trigger points in these muscles can refer pain into the viscera and even cause visceral problems (somatovisceral disease). Likewise, visceral disorders can cause pain in the abdominal musculature that can persist even after the disorder is resolved. They can also refer pain into the low back. It is helpful to do some preparatory work on the abdomen prior to deeper manual therapy on specific muscles in order to stimulate local blood flow and relax the superficial musculature. This work may include general massage techniques such as effleurage as well as myofascial stretching. Figure 7-1 Myofascial stretch of abdomen (Draping option 2)

Manual Therapy for the Abdomen Myofascial Stretching The client lies supine. The therapist stands beside the client at the hips. Place one hand flat on the upper abdomen on the near side of the client, the fingers resting just inferior to the rib cage Cross the other hand over the first and place it on the lower abdomen on the far side of the client, the fingers over the ASIS (anterior superior iliac spine) (Fig. 7-1). Let the hands sink into the tissue until they engage the superficial fascia of the abdomen. Press the hands apart without allowing them to glide on the skin. Hold for release. Repeat on the opposite side. P.275 Rectus Abdominis REK-tus ab-DAHM-in-iss The lumbar/abdominal muscles constitute one of the muscle groups chiefly implicated in complaints of low back pain. The others are the buttock muscles, pelvic floor muscles, and iliopsoas, all of which are addressed in the next chapter. Etymology Latin rectus, straight, upright + abdominis, of the abdomen Comment Rectus abdominis (Fig. 7-2) is composed of a series of muscle bodies separated by tendinous intersections and divided in the center by the linea alba (Latin linea, line + alba, white). This muscle connects the anterior thorax (rib cage) to the anterior pelvis (pubis). It flexes the spine and resists extension of the spine. Attachments Inferiorly, to the crest and symphysis of the pubis Superiorly, to the xiphoid process and fifth to seventh costal cartilages

Figure 7-2 Anatomy of rectus abdominis Palpation Discernible at the pubis; discernible at the edges with the fingertips from the pubis to the rib cage, although difficult to distinguish in obese clients. Its architecture is parallel, and the fibers are superior-inferior. Action Flexes the lumbar vertebral column Draws the thorax inferiorly toward the pubis Referral Areas Over the abdomen from the xiphoid process to the pubis

Across the back just below the scapulae; the region around the xiphoid process (epigastrium, precordium) Across the top of the buttocks (iliac crest) and sacrum Into the lower lateral quadrant of the abdomen Mid-abdomen just inferior to umbilicus (Also abdominal fullness, dysmenorrhea) Other Muscles to Examine Pyramidalis Serratus posterior inferior Iliopsoas Abdominal obliques Transversus abdominis Gluteal muscles Quadratus lumborum P.276 Figure 7-3 Stripping of rectus abdominis (Draping option 2)

Figure 7-4 Stripping of lateral border of rectus abdominis (Draping option 2) Manual Therapy Stripping (1) The client lies supine. The therapist stands beside the client at the hip. Place the fingertips on one side of the rectus just superior to the pubis. Pressing firmly into the tissue, slide the fingertips superiorly along the muscle to its attachments on the ribs (Fig. 7-3). Repeat the same procedure on the other side.

Figure 7-5 Stripping of lateral border of rectus abdominis with fingertips (A) or supported thumb (B) (Draping option 2) Stripping (2) The client lies supine. The therapist stands beside the client at the waist. Place the fingertips on the lateral border of the rectus just above the pubis. Pressing firmly into the tissue, rotate the hand so that the fingertips move superiorly along the edge of the muscle (Fig. 7-4). Beginning just superior to the previous spot, repeat this procedure all the way along the muscle to the rib cage. Repeat the same procedure on the other side.

P.277 Figure 7-6 Compression of rectus abdominis attachments at the pubis (Draping option 2) Stripping (3) The client lies supine. The therapist stands beside the client at the hip. Place the fingertips (Fig. 7-5A) or supported thumb (Fig. 7-5B) on the lateral border of the rectus just above the pubis. Pressing firmly into the tissue, slide the fingertips or thumb along the muscle to its attachments on the rib cage. Repeat the same procedure on the other side. Compression The client lies supine. The therapist stands beside the client at the chest.

Place the supported thumb at the attachment of the rectus to the pubis at the side nearest you. Press the muscle firmly against the bone, looking for tender spots. Hold for release. Move the hand medially to the next spot and repeat until you reach the linea alba at the center (Fig. 7- 6). Repeat this procedure on the other side. Figure 7-7 Cross-fiber stroking of rectus abdominis (Draping option 2) Cross-fiber Stroking The client lies supine. The therapist stands beside the client at the waist. Place the tip of the thumb on rectus abdominis at the linea alba (center line) just superior to the pubic symphysis, with the fingertips resting on the abdomen laterally. Pressing firmly into the tissue, slide the tip of the thumb laterally toward the fingertips. Beginning just superior to the previous point, repeat this procedure. Repeat the same procedure (Fig. 7-7), continuing along the rectus until you reach the rib cage. Repeat this procedure on the other side.

P.278 Pyramidalis pi-RAM-I-DAL-iss Etymology Latin pyramidalis, shaped like a pyramid Comment Pyramidalis (Fig. 7-8) very commonly occurs on one side only, and may be absent in many people. It may harbor a trigger point at its attachment to the pubis. Attachments Inferiorly, to the crest of the pubis Superiorly, to the lower portion of the linea alba Figure 7-8 Anatomy of pyramidalis Palpation Not normally distinguishable from rectus abdominis.

Action Tenses the linea alba Referral Areas To its attachment to the pubis Along the midline to the umbilicus Other Muscles to Examine Rectus abdominis Iliopsoas Abdominal obliques P.279 Figure 7-9 Compression of pyramidalis (Draping option 2)

Manual Therapy Compression The client lies supine. The therapist stands beside the client at the hip. Place the thumb on pyramidalis, just superior and lateral to the symphysis pubis (Fig. 7-9). Press firmly into the tissue, examining for tenderness. Hold for release. Repeat this procedure on the other side. P.280 Abdominal Obliques oh-BLEEKS Etymology Latin obliquus, slanting, diagonal Comment The external and internal abdominal obliques (Figs. 7-10, 7-11) run in the same respective directions as the external and internal intercostals. A good way to remember their directions is to place one hand on the opposite side of the abdomen with your fingers pointing diagonally downward, then place the other hand on top of it pointing perpendicularly. The top hand represents the externals, the bottom hand the internals (Fig. 7-12). Figure 7-10 Anatomy of external oblique

Attachments External: Superiorly, to the fifth to twelfth ribs Inferiorly, to the anterior half of the lateral lip of the iliac crest, the inguinal ligament, and the anterior layer of the rectus sheath Internal: Inferiorly, to the iliac fascia deep to the lateral part of inguinal ligament, to the anterior half of the crest of the ilium, and to the lumbar fascia Superiorly, to the tenth to twelfth ribs and the sheath of the rectus abdominis Palpation Discernible only when contracted by having the supine client raise one shoulder toward the opposite side of the body. Architecture is parallel and the fibers are, as the name implies, oblique in two opposed directions (Fig. 7-12). P.281 Figure 7-11 Anatomy of internal oblique Actions

Bilaterally, increase intra-abdominal pressure and flex the spine. Unilaterally, assist in lateral flexion and rotation of the spine. Referral Areas To the epigastric region (below the xiphoid process between the costal arches), over the lower chest, and diagonally below the costal arch The lower lateral quadrant of the abdomen, into the groin and the testicle, up over the abdomen to the pubis, the umbilicus, and the costal arch Other Muscles to Examine Rectus abdominis Iliopsoas Quadratus lumborum Figure 7-12 Mnemonic hand position for direction of external and internal obliques (top hand, external; bottom hand, internal)

P.282 Manual Therapy Stripping The client lies prone. The therapist stands beside the client at the chest. Place the hand between the client's abdomen and the table (Fig. 7-13A) with the palm on the abdomen and the fingertips just superior to the pubis at the attachment of the inguinal ligament. Pressing firmly upward into the tissue, slide the fingertips superolaterally along the muscle to the rib cage (Fig. 7-13B). (NOTE: the client is shown standing in the photograph for illustration of the procedure.) Beginning at the same spot, repeat this procedure at a more oblique angle until the whole surface of the abdomen has been treated. Repeat the same procedure on the other side.

Figure 7-13 Client prone (A) for stripping of obliques with fingertips (Draping option 7) (B) position for demonstration as if prone P.283 Transversus Abdominis trans-VERS-us ab-DOM-in-iss Etymology Latin trans, across + versus, turned Comment Transversus abdominis (Fig. 7-14) lies deep to the other abdominal muscles. There is no separate manual treatment for it that is appropriate to this text.

Attachments Laterally, to the seventh to twelfth costal cartilages (interdigitating with fibers of the diaphragm), lumbar fascia, iliac crest, and inguinal ligament Medially, to the xiphoid cartilage and linea alba and, through the conjoint tendon, to the pubic tubercle and pecten Figure 7-14 Anatomy of transversus abdominis Palpation Not palpable. Action Compresses the abdomen Referral Areas Along and between the anterior costal margins

Other Muscles to Examine Rectus abdominis Abdominal obliques Manual Therapy P.284 Not applicable Muscles of the Lower Back Comment Shoulder muscles in the lower back are covered in Chapter 4. Vertebral muscles in the lower back are covered in Chapter 6. Quadratus Lumborum kwa-DRAY-tus lum-BOR-um Etymology Latin quadratus, four-sided + lumborum, of the loins Comment When cinematographers have to shoot a scene in which the camera is moving around, either on someone's back or on a truck, they use a device called Steadicam™—to prevent the movement of the carrier being transferred to the camera. The same coordination between our upper and lower bodies is needed when we perform complex actions with our eyes and hands while running or riding on horseback, or keep our feet and legs steady while performing actions with our arms. In addition to its responsibility for side-bending, quadratus lumborum performs this service. For this reason, you will often find quadratus lumborum problems in horseback riders, kayakers, golfers, and anyone whose activities involve separation of movement between the upper and lower body.

Figure 7-15 Anatomy of quadratus lumborum Quadratus lumborum (Fig. 7-15) is not an easy muscle to access manually, as it lies deep to the lumbar paraspinal muscles (erector spinae) and the thick layers of fascia and aponeurotic tissue of the lumbar region. It can be approached obliquely with the elbow just adjacent to the lumbar paraspinal muscles or laterally with the fingers or thumbs. Attachments Inferiorly, to the iliac crest, iliolumbar ligament, and transverse processes of the lower lumbar vertebrae Superiorly, to the twelfth rib and transverse processes of the upper lumbar vertebrae Palpation Can be palpated with thumb or fingertips from the side underneath the paraspinal muscles and lumbar aponeurosis between the last rib and the iliac P.285 crest. The fibers are oblique, the upper fibers from lateral to medial, lower fibers medial to lateral, and the architecture is parallel.

Figure 7-16 Myofascial stretch of low back (Draping option 7) Actions Lateral flexion of the spine (unilaterally) Extension of the spine (bilaterally) Stabilization of the lumbar spine Referral Areas Into the buttock

Over the hip Down the back of the leg Over the iliac crest Into the groin and sometimes the testicle Into the lower lateral quadrant of the abdomen Other Muscles to Examine Iliopsoas Lumbar paraspinal muscles Gluteal muscles Piriformis and other deep lateral rotators Rectus abdominis and pyramidalis Caution In working in a superior direction on quadratus lumborum, do not place excessive pressure on the last rib. It is joined only to T12, and can be broken with pressure. Manual Therapy Myofascial Stretch The client lies prone. The therapist stands beside the client at the waist. Place the hand nearest the client's head flat on the lumbar area lateral to the vertebrae with the fingers over the iliac crest just lateral to the sacrum. Crossing the other hand over or under the first, place it flat on the thoracic area over the lowest three or four ribs. Let your hands sink into the tissue until you feel contact with the superficial fascia. Press the hands in opposite directions, with enough downward pressure to engage and stretch the superficial fascia (Fig. 7-16).

Hold until you feel significant release in the fascia. Shift both hands laterally (toward yourself) by one hand's width and repeat the technique. Compression The client lies prone or on one side. The therapist stands beside the client at the waist. P.286 Figure 7-17 Compression of quadratus lumborum with the thumb, client prone (Draping option 7)

Figure 7-18 Compression of quadratus lumborum with the client sidelying, using the thumb (A) or fingertips (B) (Draping options 11,15)

Figure 7-19 Compression of quadratus lumborum with the elbow superiorly (A) and inferiorly (B), client sidelying (Draping option 7) Grasp the client's waist laterally, with either the thumb (Figs. 7-17, 7-18A) or the fingertips (Fig. 7-18B) pressing under the erector spinae bundle into quadratus lumborum. Press firmly into the muscle, looking for tender spots, which may range from the attachments to the ilium to the attachments to the last rib. Hold for release. Compression The client lies prone. The therapist stands beside the client at the waist.

Place the elbow just lateral to the erector spinae bundle. Press firmly into the tissue, obliquely in a deep and medial direction. Hold for release. Repeat this procedure, first pressing superiorly toward the muscle's attachment to the last rib (Fig. 7- 19A), then inferiorly toward the muscle's attachment to the ilium (Fig. 7-19B). P.287 Stretch The client lies prone. The therapist stands beside the client at the waist. Place the heel of the hand just lateral to the erector spinae bundle on the opposite side of the client's body, between the ilium and the last rib. Pressing deeply toward the table, let the heel of your hand slide slowly away from you (Fig. 7-20), compressing all the muscles between the pelvis and the last rib, until your hand comes off the client's side. Figure 7-20 Stretch of quadratus lumborum with the hand (Draping option 7)

Authors: Clay, James H.; Pounds, David M. Title: Basic Clinical Massage Therapy: Intergrating Anatomy and Treatment, 2nd Edition Copyright ©2008 Lippincott Williams & Wilkins > Table of Contents > Part II - Approaching Treatment > 8 - The Pelvis 8 The Pelvis P.290

Plate 8-1 Skeletal features of the pelvic region P.291

Plate 8-2 Ligaments of the pelvic region P.292

Plate 8-3 Muscles of the anterior pelvis and pelvic floor P.293

Plate 8-4 Muscles of the pelvis, lateral view P.294

Plate 8-5 Muscles of the pelvis, sagittal section P.295

Plate 8-6 Muscles of the pelvis, posterior view P.296

Plate 8-7 Surface anatomy of the pelvic region P.297 Overview of the Region The structural, functional, and emotional importance of the human pelvis cannot be overemphasized. The pelvis balances the torso and its appendages on the legs. It is the container, support, and protector of the abdominal and pelvic organs, especially the organs of reproduction and elimination. It is therefore a very personal and intimate area. Its position and freedom of movement are of principal importance in postural alignment. Although we tend to think of the pelvis as a single entity, it is actually composed of two halves, or hemipelves, connected posteriorly at the sacroiliac joints and anteriorly at the symphysis pubis. The pelvis as a whole can be rotated forward or backward, or tilted to either side. Each hemipelvis, however, can have a greater or lesser anterior or posterior rotation in relation to the other, resulting in what is called a torqued pelvis. Since each hemipelvis is the site of one acetabulum, in which the head of the femur rests, the position of the hemipelvis will affect the position of the hip joint and its corresponding leg. The anterior or posterior rotation of the pelvis as a whole will also affect the normal curve of the lumbar spine, which in turn will affect the carriage of the entire upper body. A lateral tilt in the pelvis, determined by the relative positions of the two sacroiliac joints, will result in an uneven

distribution of the body weight on the legs, and will require a compensatory shifting of the rib cage and its attached structures. Any combination of tilt or rotation in the frontal or sagittal planes and torque of the hemipelves will result in a postural misalignment that is likely to cause a wide variety of myofascial problems in both the lower extremities and the entire upper body. In addition to postural issues, tightness or trigger points in the muscles of the pelvis can interfere with reproductive or eliminatory functions and can refer pain into the viscera. The muscles of the pelvis should always be considered and addressed in any interview and examination. Because of the intimate nature of the pelvic region, it is necessary to approach examination and treatment with a great deal of sensitivity to the client's feelings and concerns with regard to privacy and modesty. Examination and treatment should be carried out only with informed consent. P.298 Psoas Major (Iliopsoas) SO-az MAY-jer Etymology Greek psoa, the muscles of the loins + Latin major, larger Overview Psoas major (Fig. 8-1), which joins iliacus at the groin to form iliopsoas, is one of the most important muscles in the body, not only for its primary function as hip flexor, but also for its postural and clinical significance. In four-legged domestic animals, iliopsoas has little challenging work to do, since it has no real postural function and acts only to swing the hind leg forward in walking. For this reason, it tends to be a tender cut of meat: it is the tenderloin or filet, the source of the filet mignon. In humans, the story is altogether different: since we walk upright, much greater muscular effort is required to flex the hip and lift the leg. In addition, psoas plays a major role in determining the positioning of the pelvis and low back in relation to each other.

Figure 8-1 Anatomy of psoas major During gestation, the hips of the fetus remain fully flexed most of the time. If you observe human babies, you will notice that they do not lie flat—the hips tend to stay partially flexed. In fact, a baby does not usually attain full extension of the hips until she begins to walk. This full extension is necessary for a relaxed and comfortable upright posture. Children spend a great deal of time sitting, either in class at school, or at home studying or watching television. Most adults spend even more time in this position at desks or computers or, again, in front of the television. Iliopsoas, therefore, spends a lot of time shortened and very little time stretched. Psoas attaches to the lumbar vertebrae and passes downward through the abdominal cavity to the groin, where it merges with iliacus and P.299 passes over the anterior rim of the ilium, then obliquely in a posterior and inferior direction to attach to the lesser

trochanter of the femur. In this way, it uses the anterior rim of the ilium as a pulley, exerting an inferior and posterior force against it. Thus, by pulling forward on the lumbar spine and pressing downward and backward on the anterior inferior ilium, it rotates the pelvis forward and draws the lumbar curve into lordosis (Fig. 8-2). This effect can easily be seen in children, who tend to have this rotation and lordosis to a pronounced degree, and it is quite common for this postural tendency to persist into adulthood to a lesser, but still measurable, extent. One result of an anterior pelvic rotation is to shift the weight of the contents of the abdominal cavity forward, causing the abdomen to protrude. In addition, this rotation moves the hip joint posteriorly, placing strain on the muscles controlling the knees and ankles. An exaggerated lumbar lordosis requires compensatory positioning of all the structures superior to it. The clinical significance of psoas is both indirect and direct: indirect, in the postural influences described above, and direct, by referring pain into the low back, abdomen, groin, and upper thigh. The pain referral patterns of psoas can include the viscera. In this way, psoas problems can mimic pain from visceral causes. Attachments Superiorly, to the vertebral bodies and intervertebral disks of the twelfth thoracic to the fifth lumbar, and to the transverse processes of the lumbar vertebrae Inferiorly, with the iliacus muscle to the lesser trochanter of the femur Palpation Belly is discernible with the fingertips just below and two to three inches to either side of the umbilicus by having the client raise the corresponding leg. Lower psoas is discernible in the groin below the inguinal ligament just medial to the iliopubic eminence. Architecture is parallel, and fibers run vertically except where they pass over the pelvic rim.

Figure 8-2 Influence of psoas major on anterior pelvic rotation Action Flexes the hip; is a major postural muscle Referral Areas To the medial lumbar region To the abdomen from the epigastrium to the groin To the anterior thigh from the groin halfway to the knee

Other Muscles to Examine Iliacus Rectus abdominis Abdominal obliques Diaphragm Hip adductors Quadratus lumborum Lumbar erector spinae muscles P.300 Manual Therapy Compression The client lies supine, with the hip and knee on the side to be treated flexed about 45º. The therapist stands beside the client, at the client's hip. Place the fingertips of the hand nearest the client on the near side of the abdomen, a few inches inferior and lateral to the navel (Fig. 8-3). Press firmly and slowly into the abdomen, moving the fingertips in a circular fashion to nudge the viscera out of the way. When you encounter the psoas, press into the muscle searching for tender areas (Fig. 8-4). Hold for release. Move the hand caudally so that the fingertips are just inferior to the previous spot. Repeat this procedure until you reach the inguinal ligament. Repeat at the groin below the inguinal ligament (the circular motion is not necessary here) (Fig. 8-5). This work on psoas may also be done from the opposite side of the client, with the client in a sitting position (Fig. 8-6), or standing bent over the table.

Figure 8-3 Position of hand for work on psoas major (Draping option 5) Figure 8-4 Compression of psoas major (Draping option 5)

Figure 8-5 Compression of iliopsoas below the inguinal ligament (Draping option 5) P.301 Compression of the Inferior Attachment The client lies supine. The therapist stands beside the client at the client's knees. Place the supported thumb on the anterior thigh, about two inches below the groin, medial to the rectus femoris. Press firmly into the tissue, looking for the attachment to the lesser trochanter (Fig. 8-7). If tender, hold for release.

Figure 8-6 Compression of psoas major with client in sitting position (Draping: underwear, swimsuit, or exam gown)

Figure 8-7 Compression of attachment of psoas major to lesser trochanter (Draping option 5) P.302 Iliacus il-lee-ACK-us, il-EYE-a-cus Etymology Relating to the ilium: Latin ilium, flank, groin Overview See discussion of psoas, above. Attachments Superiorly, to the iliac fossa (Fig. 8-8) Inferiorly, to the tendon of psoas, the anterior surface of lesser trochanter, and the capsule of the hip

joint Palpation Can be discerned with the fingertips curled over the ilium. The architecture is convergent. Action Flexes the hip Referral Areas See psoas, above Other Muscles to Examine See psoas, above Manual Therapy Stripping and Cross-fiber Stroking The client lies supine. The therapist stands beside the client at the hip. Place the fingertips just medial to the ilium. Pressing firmly into the tissue, move the fingertips back and forth and rotate the hand from side to side to slide the fingertips across the muscle (Fig. 8-9A). This procedure may also be carried out with the supported thumb (8-9B), or with the client prone and the hand underneath the pelvis (Fig. 8-9C).

Figure 8-8 Anatomy of iliacus P.303

Figure 8-9 Stripping and cross-fiber stroking of iliacus with fingertips (A), supported thumb (B), and from underneath the client (C) (Draping options 7, 2) P.304 Psoas Minor SO-az MY-ner Etymology Greek psoa, the muscles of the loins + Latin minor, smaller

Overview Psoas minor (Fig. 8-10) is absent in approximately 40% of the population, and in some people may be present on one side only. It has no recorded clinical significance. Attachments Superiorly to the bodies of the twelfth thoracic and first lumbar vertebrae and the disk between them Inferiorly, to the iliopubic eminence via the iliopectineal arch (iliac fascia) Figure 8-10 Anatomy of psoas minor Palpation Not palpable Action Assists in flexion of the lumbar spine